One of the World's Tiniest, Poorest Countries Is Redefining HIV Care

Former sex workers participating in a World Bank program to address HIV/AIDS sing and dance to religious songs in Rwanda’s Muhanga district, on June 13, 2007. (Reuters/Arthur Asiime)

In the past decade, sub-Saharan Africa, the world’s poorest region, has made enormous strides in the fight against HIV. There are now more than 7.5 million people receiving antiretroviral therapy, 150 times as many as a decade ago. Medications have become more effective and easier to take, and they are now combined so that many patients take as little as one pill a day. HIV testing has become more widely available, and we are detecting the virus at earlier stages before too much damage is done.

With World AIDS Day upon us, however, it is important to keep in mind that the needs in this part of the world are still grim. The U.N. estimates that only 45 percent of pregnant women are tested for HIV and only 35 percent of infants born to mothers with HIV are tested for the virus on time. Treatment for children and adolescents lags dramatically behind that of adults. Around the world, 1.7 million people die of the disease every year. Unfortunately, the UNAIDS goal of 15 million people on treatment by 2015 seems a long way off, and HIV vaccines and “cures” remain in early investigatory phases.

Yet in Rwanda, where just 20 years ago a genocide claimed approximately 1 million lives, the government has transformed HIV care for the poor by redefining the standards for successful treatment. More than three decades into the epidemic, many national and international agencies are still counting the basics—how many people get infected, how many people receive medication, how many patients die. Success in Rwanda, meanwhile, is measured not in the number remaining alive, but rather in how many are actually able to take their medications as directed and suppress the virus in their bodies to a level where it is essentially non-existent. In Rwanda, success is achieved when people living with HIV can earn a living, support their family, raise their children, and care for their community no differently than their peers.

As a physician working for Partners in Health in Rwanda, I have witnessed the impact of this relentless approach to HIV care and treatment, and the stabilizing and uplifting impact it has had on the lives of Rwandans. Patients who would have previously been hospitalized with severe and end-stage complications of HIV are now coming for regular, preventive care. Families and communities previously devastated by the dual impact of insecurity and HIV are now thriving hubs for HIV prevention and treatment. I’ve come to realize that this tiny East African country may have large lessons to share with the global HIV movement.

Rwanda is not without its challenges. Though roughly the size of New Hampshire, it is home to more than 200,000 people living with HIV, including 27,000 children. In the capital city of Kigali, nearly one in 12 women between the ages of 15 and 49 are infected with the virus. The average life expectancy, though rising, remains 55 years (compared with 79 years in the U.S.).

Still, in a country where the average income is less than $2 a day, more than 120,000 patients are now being treated for HIV, a tenfold increase since 2004. Put another way, 91 percent of patients in Rwanda requiring HIV medications have access to life-saving treatment, compared with 54 percent worldwide.

Perhaps even more encouraging is that 98 percent of women receive HIV testing during their prenatal visits. Rwanda is one of the first sub-Saharan countries to virtually eliminate the transmission of HIV from mothers to newborn babies. As a result, the number of new HIV cases has been cut by half in the last decade, and Rwanda has made a big step toward fulfilling the dream of “an AIDS-free generation.”

How has Rwanda, one of the 20 poorest countries in the world, managed to become a model for HIV care?

While many countries continue to approach the HIV epidemic in isolation, Rwanda has managed to integrate its response to HIV within its broader platform for social and economic development. Having spent the past three years working in rural Rwanda, it’s astonishing to see how investments in health care infrastructure have manifested in some of the country’s hardest-to-reach areas. More than 400 new health facilities dot the rural landscape, effectively decentralizing health care from major cities to villages. To ensure care is accessible, the government offers community-based health insurance that costs barely $5 per year, which has resulted in health care coverage for more than 90 percent of the population.

In a country with only one doctor for every 17,000 people, nurses and community health workers have been trained and mentored to provide HIV services that were previously only available from physicians at referral centers. While aggressive mass media campaigns by the government and international organizations feverishly encourage the general public to “Know Your Status,” targeted outreach programs are simultaneously focusing on high-risk groups. Rwanda is taking the lead here by providing antiretroviral medications to groups that did not previously receive them: pregnant women, young children, female sex workers, men who have sex with men, and those with sexual partners who are not infected. This combined strategy is progressively transforming HIV from a stigmatized infectious disease to a chronic condition similar to hypertension, diabetes, and depression. I am confident that replicating Rwanda’s approach in other countries, both rich and poor, could effectively globalize this transformation.

Recent studies show that 83 percent of Rwandans living with HIV are successful in suppressing the virus, more than double the success rate that has been reported for patients in the U.S. Partners in Health, which helps to provide treatment services for over 10,000 patients in Rwanda, has demonstrated that additional social, economic, and nutritional support, largely delivered via community health workers selected and trained from the patients’ own villages, further increases the likelihood that a patient is able to suppress the virus.

More and more evidence is emerging that the earlier HIV medications are started, the better it is not only for the individual patient, but also for preventing the spread of the virus to others. It’s no surprise then that Rwanda is poised to be one of the first developing countries to roll out new World Health Organization (WHO) guidelines that recommend starting HIV medications earlier for all patients rather than waiting for the body’s immune system to be severely compromised, a move WHO predicts will save 3 million lives and prevent 3.5 million infections worldwide by 2025.

The global community should take a moment on World AIDS Day to celebrate its successes and improve on its failures. But most of all, it should learn from its high achievers—even those that are found in the least expected places.

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Neil Gupta is the deputy clinical director for Partners in Health in Rwanda. He is an associate physician in the Division of Global Health Equity at Brigham and Women’s Hospital and an instructor at Harvard Medical School.